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UNLABELLED Evaluation of the quality of atrial sensing is indispensable to monitor the performance of VDD single-lead systems. In addition to counters, a new VDD system offers storage of intracardiac electrograms (EGMs). The clinical contribution of stored EGMs in a VDD pacemaker was prospectively examined in a multicenter study, and the reliability of its counters was evaluated on the basis of EGM information. METHODS A VDD system (Pulsar 870, Guidant Co.) was implanted in 46 patients with atrioventricular block. EGM storage was activated upon detection of ventricular tachycardia (VT), recurrent premature ventricular complexes (PVCs), and mode switch ("atrial tachy reaction," ATR). Stored EGMs were retrieved before discharge of the patients from the hospital, and at 6-week, 3-month, and 6-month follow-up. RESULTS A total of 440 stored EGMs were retrieved and analyzed. Of 30 VT episodes detected, 2 (7%) were confirmed, and all others were attributable to ventricular oversensing. One postmortem interrogation documented VT as the cause of sudden death. Of 175 EGMs stored upon detection of PVCs, 43 episodes (25%) were confirmed and 124 (70%) showed intermittent atrial undersensing with spontaneous AV conduction; in 8 episodes (5%) no abnormality was observed. Of 235 episodes stored upon ATR, 82 (35%) were confirmed and 153 were due to atrial oversensing. CONCLUSIONS (1). Stored EGMs indicated a high percentage (69%) of event misdiagnosis by the pacemaker. Thus, pacemaker counter information without the availability of stored EGMs should be interpreted with caution. (2). Misclassified events are of high clinical importance since they unmask otherwise unsuspected intermittent under- or oversensing.

Thrombolytic treatment efficacy is greater when the delay between onset of pain and treatment is short. One way to shorten this delay is to give treatment at home, but one cannot recommend this technique if it has not been demonstrated first, that pre-hospital thrombolysis is feasible and safe, and second, that it is useful. We have been able to demonstrate that pre-hospital thrombolysis with APSAC is feasible and safe. Our findings are similar to those of other teams using other drugs. Whether pre-hospital thrombolysis is useful has not been adequately assessed; and we consider that first, the benefit of pre-hospital vs in-hospital thrombolysis must be determined, and second, the results of a study involving many centres, with various levels of training, practicing pre-hospital thrombolysis must be examined. Two large scale studies are currently being performed. One in Seattle, uses left ventricular ejection fraction as the major end-point, whereas the other, the European Myocardial Infarction Project, (EMIP) is using total mortality. Data currently available indicate that pre-hospital thrombolysis with APSAC is feasible, easy and safe. We hope that we will very soon be able to answer the last question: is it useful?

AIM The purpose of this study was to evaluate the performance of a new VDD pacing system incorporating a high impedance, single-pass VDD lead. The new lead is a bipolar, steroid-eluting, high impedance lead with a full-ring atrial dipole. METHODS AND RESULTS The system was implanted in 46 patients with high degree atrioventricular (AV) block. Patients were followed at pre-discharge, 6 weeks, and 3 months. The mean measured P-wave amplitude was stable, with values between 1.18 and 1.43 mV. Atrial sensing was reliable during short-term evaluation at rest and in the sitting position, with AV-synchronous stimulation between 98.79 +/- 6.90% and 99.73 +/- 1.47%. Holter recordings after 6 weeks demonstrated AV-synchronous stimulation in 99.57 1.03% of all P-waves. Lead impedance was stable during follow-up, with mean values between 1000 and 1167 Q. Mean ventricular pacing thresholds (at 0.5 ms) were 0.47 V at implant, 0.49 V at pre-discharge, 0.74 V at 6 weeks, and 0.72 V at 3 months. R-wave amplitude remained stable between 14.9 and 16.7 mV during follow-up. CONCLUSION This new single-pass VDD lead system provided reliable atrial sensing and stable high impedance stimulation during a 3-month follow-up period.

The incidence of sudden death remains high. The basic causes are related to ischemic heart disease and heart failure. Automatic defibrillation is the best treatment, as first conceived and implanted by Mirovski twenty years ago. MARKERS OF RISK OF SUDDEN DEATH: Left ventricular dysfunction, functional class and spontaneous and induced ventricular hyperexcitability identify a high-risk population.Drug treatments used in the post infarction period or for heart failure (beta-blockers, converting enzyme inhibitors and amiodarone) have demonstrated a certain efficacy in preventing sudden death. However, different therapeutic trials comparing the efficacy of defibrillators and drug treatments have demonstrated the 20 to 46% superiority of defibrillation in terms of reduced mortality.

Several studies have demonstrated that implantable defibrillators improve survival in patients with a very high risk of sudden death. INDICATIONS FOR PRIMARY PREVENTION: The most obvious indication is for young patients with severe recurrent rhythm disorders and generally good left ventricular function. However, most of the candidates have severe left ventricular dysfunction due to post infarction ischemia or dilated cardiomyopathy who develop syncopal or hemodynamically poorly tolerated ventricular tachycardia or who have survived a first episode of sudden death. PROPHYLACTIC INDICATIONS: Automatic defibrillation should be proposed for patients with factors of risk of sudden death such as left ventricular dysfunction or infarction sequelae.

The authors report their experience with dual-chamber pacing in hypertrophy obstructive cardiomyopathy. 22 patients (14 women and 8 men) mean age 60 +/- 13 years were implanted between 1992 and 1998. The criteria for pace-maker implantation were the presence of severe symptoms related with hypertrophy obstructive cardiomyopathy (dyspnea, angina, syncope) and left ventricular outflow tract gradient at mean 30 mmHg. Before pacing, all patients received a medical therapy which included beta-blockers or calcium inhibitors. This treatment was considered as ineffective or responsible of side effects. Patients were followed-up at mean 35.1 +/- 20.3 months. During this period, symptoms improved (mean NYHA class 2.7 +/- 0.5 before pacing vs 1.4 +/- 0.5 after pacing) and left ventricular outflow tract lowered from 95.4 +/- 40.8 to 39.3 +/- 20.5 at 6 months. 34.3 +/- 23.4 at one year and 26.5 +/- 21 at the end of follow-up. Seven patients had RF ablation of atrio-ventricular junction for paroxysmal atrial fibrillation or for lack of hemodynamic improvement with pacing. This procedure permits a significative lowering of gradient and a better ventricular filling. In conclusion, dual-chamber pacing is effective for treatment of hypertrophy obstructive cardiomyopathy when medical therapy is ineffective or bad tolerated at condition of: perfect pacing with permanent ventricular capture and optimal AV delay; RF ablation of AV junction in one third of cases; medical therapy systematically associated in all patients.

We report a case of an almost permanent ventricular tachycardia that occurred in a 39-year-old man a few weeks before admission to the hospital. This arrhythmia was noticeable by its total irregularity and its association with a left ventricular dysfunction. The precise nosological frame for the arrhythmia was difficult to define. This case presented as an idiopathic left ventricular tachycardia, the features of which could be consistent with an atypical parasystole. The rapid abolition of the rhythm disturbance by oral verapamil without recurrence at 6 months resulted in normalization of the contractile function.

To assess the effects of piroximone, a phosphodiesterase inhibitor, on right ventricular function in patients with heart failure.Randomized study: patients were randomly assigned to the piroximone infusion rate of 5 or 10 micrograms/kg/min.Cardiologic intensive care unit.12 consecutive patients with severe heart failure.Right heart catheterization was performed using a Swan-Ganz ejection fraction thermodilution catheter.Measurements of right ventricular ejection fraction (RVEF), end-diastolic and end-systolic right ventricular volumes were obtained using the thermodilution principle. To determine contractility indexes, the relationships between end-systolic pulmonary arterial pressure (ESPAP) over right ventricular end-systolic volume (RVESV) and ESPAP over RVEF were calculated during the infusion of prostacyclin at incremental infusion rates of 2, 4, 6 and 8 ng/kg/min. The slope of the relation between ESPAP over RVESV shifted during piroximone therapy from 7.635 +/- 1.632 to 1.975 +/- 0.432 (p0.01) and from 6.092 +/- 1.99 to 1.028 +/- 0.853 (p0.05) at 5 and 10 micrograms/kg/min piroximone infusion, respectively. The slope of the relation between ESPAP over RVEF decreased from -0.414 +/- 0.296 to -0.821 +/- 0.257 (p0.01) and from -0.127 +/- 0.048 to - 0.533 +/- 0.135 (p0.05) at 5 and 10 micrograms/kg/min piroximone infusion, respectively.This study suggests a positive action of piroximone on right ventricular contractility at these 2 dosages. This approach using this type of catheter allowed us to determine right ventricular inotropic indexes.

This study was undertaken to assess the haemodynamic effects of the combined infusion of prostacyclin and piroximone, a phosphodiesterase inhibitor, in 18 patients with severe congestive heart failure. Right heart catheterization was performed with a Swan-Ganz thermodilution catheter and arterial blood pressure was monitored using a radial line. After baseline haemodynamic measurements, prostacyclin was administered in all patients at the incremental infusion rate of 2, 4, 6 and 8 and 10 ng.kg-1.min-1 during 15 min each. After recovery of baseline haemodynamics, patients were randomly assigned to the piroximone infusion rate of 5 or 10 micrograms.kg-1.min-1 or placebo. After 24 h piroximone or placebo infusion, the same prostacyclin protocol was applied. Prostacyclin infusion added to piroximone resulted in a significant improvement in haemodynamics, as compared to the group receiving prostacyclin added to placebo. As compared to the curve observed with the placebo infusion, 10 ng.kg-1.min-1 prostacyclin infusion resulted in a further increase in cardiac index, by 41 and 38% (P0.01) at the piroximone-infusion rates of 5 and 10 micrograms.kg-1.min-1, respectively, whereas systemic vascular resistance decreased by 25 and 21%, respectively (P0.01). Additionally, a further decrease in pulmonary capillary wedge pressure by 13 and 11% (P0.05) and in pulmonary vascular resistance by 21 and 19% (P0.05) was observed at the piroximone-infusion rates of 5 and 10 micrograms.kg-1.min-1, respectively. Consequently, stroke work index increased significantly, as compared to the group receiving prostacyclin added to placebo. This haemodynamic improvement occurred without significant changes in heart rate and mean arterial pressure. Thus, this study shows that in patients with severe congestive heart failure, short-term infusion of prostacyclin is safe and has additive haemodynamic effects on phosphodiesterase inhibitors.

Automatisch gespeicherte EGM verbessern die Qualitat der Schrittmachernachsorge entscheidend, da sie einen kontinuierlich aktiven Monitor darstellen, der zum einen Informationen uber Arrhythmien des Patienten bietet, zum anderen aber auch indirekt Ruckschlusse uber die Schrittmacherfunktion zulast. In einem hohen Prozentsatz wurden die Episoden falsch klassifiziert: Bei 65,1% der ATR-Reaktionen lag tatsachlich atriales Oversensing vor, bei 70,9% der „rezidivierenden VES” intermittierendes atriales Undersensing. Diese Daten unterstreichen die Bedeutung gespiecherter EGM und warnen davor, Speicherangaben blind zu vertrauen. Auch die falsch klassifizierten EGM sind von hohem diagnostischen Wert, da sie indirekt Auskunft uber Sensingprobleme geben konnen, die gerade bei VDD-Systemen sorgfaltig uberwacht werden sollten.

The prognosis of cardiogenic shock in the acute phase of myocardial infarction has been transformed since the introduction of techniques of myocardial revascularisation. We report the case of a patient in cardiogenic shock after a large anterior myocardial infarct in whom failure of early thrombolytic therapy led to referral for emergency percutaneous transluminal coronary angioplasty. The success of the procedure on the patient's haemodynamic condition was life-saving. The originality of this case resides in the fact that revascularisation concerned the left main coronary stem.

Cardiac transplantation is theoretically the optimal final treatment of terminal cardiac failure but the indications, especially in the emergency situation, should be carefully considered. Sympathomimetic agents are of limited use in patients with severe cardiac failure partly because of the down regulation of the myocardial beta-receptors. The phosphodiesterase inhibitors, represented by enoximone, are valuable because of their action on the cardiac muscle (inotropic and lusitropic) and their direct systemic vasodilator effect. Enoximone can be administered by intravenous bolus resulting in a rapid onset of action (peak at 30 minutes) with a prolonged effect due to its hepatic metabolites. The authors' experience in this indication dates over 5 years and over 50 patients were included. A preliminary study in 34 patients with cardiac failure resistant to betamimetic drugs, referred to the intensive care unit for urgent cardiac transplantation, or, in the absence of a donor, circulatory assistance is reported. A Swan Ganz catheter and radial artery canula were inserted for haemodynamic monitoring and enoximone was administered in an intravenous bolus over 15 minutes every 8 hours in addition to sympathomimetic agents. A haemodynamic improvement was observed after the 30th minute in 30 patients. The cardiac index increased from 1.82 to 2.67 l/mn/m2 and the pulmonary capillary pressures decreased from 30.8 to 18.9 mmHg. Systemic arterial resistances fell from 2,170 to 1,520 dynes.s.cm-5. No haemodynamic improvement was observed in 4 patients who were treated by mechanical ventricular assistance. After investigations to detect contra-indications to cardiac transplantation, 12 of the 30 patients remained candidates for cardiac transplantation.(ABSTRACT TRUNCATED AT 250 WORDS)

Two-dimensional echocardiography with intravenous injection of dipyridamole (0.56 mg/kg) was performed in 33 consecutive patients with acute (2 +/- 2 days) postero-inferior myocardial infarction for semiquantitative segmental wall motion analysis. The results were compared with those of coronary angiography which was carried out during the hospital period. After a second evaluation of the recordings the following results were obtained: feasibility: 94 per cent with 85 per cent of segments analysed. Residual ischaemia in the first days of myocardial necrosis was common (70%). The ischaemia was often clinically silent including during the investigation (61%). When pain occurred, it always followed changes in regional wall motion. The dipyridamole test suggested multivessel disease with a sensitivity of 72 per cent and a specificity of 90 per cent, and residual arterial stenosis with a sensitivity of 75 per cent ans specificity of 80 per cent the secondary effects were minor. The main limitation of the test is related to the distinction between pharmacological and physiologic ischaemia. A positive test was associated with lesions justifying myocardial revascularisation (coronary bypass or angioplasty) in 19 out of 23 cases but with a very poor correlation with the topography of the coronary lesions. A negative test indicated arterial occlusion, residual stenosis with extensive myocardial damage or a normal coronary angiogram. Therefore, the dipyridamole echocardiography test may help identify a group of patients with little or no myocardial ischaemia in whom invasive investigations could be deferred; these patients contrast with the group with a positive test indicating residual ischaemia in which the coronary lesions should be documented by coronary angiography.

The degree of hormone-dependence of endometrial cancers may be evaluated by the presence and the rate of estradiol and mostly progesterone receptors in an endometrial fragment. The most differentiated tumors have a high receptor content, while anaplastic cancers are most of the time without them. They must be systematically determined regardless of other prognostic factors enabling to evaluate the prognosis and guide the treatment. It is presently facilitated by the method of immunochemical titration on histological section, available for estrogen receptors, disclosing the spatial and functional distribution of hormono-dependent cells.

The two large mature sacro-coccygeal teratomas reported seem to be responsible for the death of fetuses in the fifth and sixth months of pregnancy. A review of the literature shows that teratomas are exceptionally rare during this period. Their outcome depends upon the degree of maturity of the tumor, its size, whether its location is pelvic or not, the presence of any associated malformations and upon prematurity.

Treatment by phentolamine was carried out in 30 patients presenting with an acute myocardial infarction complicated by left ventricular failure, 8 of which had cardiogenic shock. The response to treatment was closely related to the level of overload of the left ventricle. Significant improvement in the haemodynamic state was only observed in the most severe cases of cardiac failure, and in these cases was accompanied by only a minimal and insignificant change in mean arterial pressure and heart rate.

The problems which are raised by surgical correction of a rupture of the septum complicating an acute myocardial infarction are illustrated by a study of 15 patients admitted for resuscitation. Rarely (3 cases) the anatomical abnormality is well tolerated, and a "planned" secondary operative procedure can then be carried out. More often (12 cases) the severity of the circulatory sequelae makes urgent surgery mandatory; these very severe cases have benefited greatly from advances in medical resuscitation, assisted circulation, and operative techniques.

Clinical findings and results of treatment in 17 patients with acute mitral incompetence are described. The lesions were secondary to a recent myocardial necrosis causing severe cardiac failure (shock, or acute left ventricular failure), and the presence of mitral incompetence was confirmed by right catherization (15 cases) and/or left ventricular angiography (13 cases). The anatomical lesions are described in 14 cases: rupture of the posterior mitral papillary muscle in 7 cases, and acute dysfunction of the muscle in 7 other cases. Eight patients were treated by an intra-aortic balloon to assist circulation, and 14 were given vasodilators (phentolamine, trinitrin) associated in 5 cases with positive inotropic drugs. Surgical treatment was given (mitral valve replacement) in 7 cases. The respective effects of vasodilators and circulatory assistance are discussed, as well as the indications for, and results of urgent surgical treatment (6 successes in 7 operations).

Transluminal coronary angioplasty (TCA) has become the treatment of choice of residual stenosis after thrombolysis for myocardial infarction, but the long-term results of TCA are imperfectly evaluated. Seventy patients underwent TCA after thrombolysis on account of a significant (greater than 50 p. 100) residual stenosis of the artery responsible for the infarction. TCA was performed less than 6 hours after the onset of symptoms in 15 patients who had neither clinical nor electrocardiographic evidence of reperfusion; 4 of these patients were in a state of cardiogenic shock. In the remaining patients TCA was performed 1 to 10 days (mean 3.2 days) after thrombolysis. A primary success was obtained in 64 patients (91 p. 100). Two patients had emergency aorto-coronary bypass. During their stay in hospital, 5 patients presented with symptoms of reocclusion which in 4 of them occurred less than 24 hours after TAC, and 2 of these 4 patients had to be reoperated upon; 2 patients died suddenly. During a 6 to 18 months' follow-up period (mean 10.5 months), the infarction recurred in 3 patients; the recurrence took place during the 3rd month in 2 of them (1 had another thrombolysis and later TAC) and during the 6th month in the third one. At 6 months, 4 patients were suffering from exertion angina and 2 asymptomatic patients had a positive exercise test. Fifty-two control coronary arteriographies were performed at 6 months. Thirteen patients (25 p. 100) had an occluded artery which was clinically silent in 11; 39 patients had a patent artery with restenosis in 7.(ABSTRACT TRUNCATED AT 250 WORDS)

Haemodynamic and echocardiographic studies of isosorbide dinitrate were conducted in 12 patients (8 men and 4 women) with left ventricular failure consecutive to recent myocardial infarction. The groups: group I received 5 mg/h and group II 10 mg/h Risordan intravenously. After one hour treatment, group I patients showed a significant fall in both PAP (from 32.3 +/- 5.3 to 26.7 +/- 6.9 mmHg; p less than 0.01) and PCP (from 21.8 +/- 4.7 to 17.3 +/- 7.7 mmHg; p less than 0.05). These haemodynamic changes were amplified after a second hour of treatment: PAP fell to 24 +/- 7.9 mmHg (p less than 0.01) and PCP to 14.2 +/- 4.4 mmHg (p less than 0.001). RAP decreased from 7.2 +/- 5.1 to 3.5 +/- 5 (p less than 0.05). There were no changes in heart rate, systemic arterial pressure, peripheral resistance, cardiac index, forward stroke work nor, on echocardiography, in ventricular diameters, shortening fraction and VCF. After one hour treatment, group II patients showed a fall in PAP (from 30.5 +/- 4.7 to 21.7 +/- 3.5 mmHg; p less than 0.01), PCP (from 21.7 +/- 4.8 to 14.8 +/- 4.9 mmHg: p less than 0.001) and RAP (from 10.3 +/- 2.9 to 7.2 +/- 2; p less than 0.01). The systolic diameter of the left ventricle was reduced from 66.3 +/- 10.6 to 64.3 +/- 11.3 (p less than 0.01). After 4 hours, improvement in PAP and PCP was maintained; the other values remained stable. The effectiveness of Risordan i.v. in left ventricular failure consecutive to acute myocardial infarction is due to reduction of filling pressures in the left ventricule. With the 10 mg/h dose, as opposed to the 5 mg/h dose, the systemic arterial pressure and the double and triple products tend to be reduced, which suggests greater effectiveness.

Enoximone (MDL 17043) is a new generation inotropic drug which acts by inhibiting phosphodiesterase and is endowed with both inotropic and vasodilator properties. The purpose of this study, which involved 23 patients aged from 18 to 75 years in NYHA class III or IV and with evidence of severe haemodynamic disturbances (cardiac index below 2.5 1/mn/m2, pulmonary wedge pressure above 15 mmHg), was to evaluate the acute haemodynamic responses to doses of enoximone that ranged from 0.25 to 2.50 mg/kg administered by bolus intravenous injection. Heart failure was either of ischaemic origin (6 cases) or idiopathic (10 cases) or due to various causes (7 cases). Group A patients (n = 11) received the drug in low doses (less than or equal to 1 mg/kg) as opposed to group B patients (n = 12) who were given high doses (greater than 1 mg/kg). Results were evaluated from the amplitude and duration of the haemodynamic response at maximum effect time (30 min). The following parameters were measured: cardiac index, pulmonary wedge pressure, systemic vascular resistance, mean arterial pressure and heart rate. Cardiac index and pulmonary wedge pressure were significantly improved in both groups (P less than 0.005): cardiac index +39 p. 100 in group A, +55 p. 100 in group B; pulmonary wedge pressure -36 p. 100 in group A, -48 p. 100 in group B; systemic vascular resistance -46 p. 100 in group B. Heart rate and arterial pressure were not significantly altered. The duration of response was 1 to 3 hours in group A patients and 4 to 8 hours in group B patients.(ABSTRACT TRUNCATED AT 250 WORDS)

It has been proven since 1986 that in myocardial infarction the sooner thrombolysis is performed the better. Forty-four patients were selected to enter a double-blind randomized trial in which they received either an acylated plasminogen streptokinase activator complex or a placebo. The injections were given intravenously at home within the first 3 hours (within the first 2 hours in 26 of them), by doctors from Mobile care units. This home treatment in the acute phase made it possible to gain 75 minutes on average, and up to 90 minutes when it was performed by an anaesthetist trained in emergency management. No serious complication, such as haemorrhagic or allergic reaction, occurred, and arrhythmia was no more frequent in the treated group than in the placebo group. Home thrombolysis did not delay admission to a cardiology Intensive Care unit (66 min. versus 64 min). Mean coronary patency was 75 per cent, and up to 82 per cent, in patients treated within 2 hours of the first symptoms. There was no significant difference between areas of reperfused or not reperfused patients in relation to time (P less than 0.08). Diagnosis sensitivity was 100 per cent. Thus, home thrombolysis is feasible and safe when performed by trained emergency medical teams and when criteria for inclusion and exclusion are fulfilled.

Surgical treatment of varicose veins occasionally can be followed by severe limb ischemia either after surgery or sclerotherapy. We report here two cases with the clinical features and the therapeutic strategy. The first case concerned a woman operated by venous stripping. A post-operative acute ischemia occurred and was treated by femoro-femoral bypass and lumbar sympathectomy. However this procedure did not avoid persistent chronic ischemia, sciatica paralysis and equinus ankle blockage. A secondary arterial procedure associated with intensive physiotherapy and ankle arthrodesis led to a poor functional result, partly because of an irreversible algodystrophia. The second case concerned a woman treated by sclerotherapy. An injection of the drug in the retro-malleolar area was immediately followed by an acute foot ischemia. Heparin, xylocaine and sodium nitroprusside perfusion avoided a foot amputation, however osteoporosis and algodystrophia occurred. A sympathectomy was necessary two years later. These dramatic complications although unusual, may occur even with experienced physicians. Therefore a great attention is always necessary during these simple procedures. In case of acute ischemia, early diagnosis and aggressive treatment are necessary, but prevention remains more secure.

The authors report their two years' experience of circulatory assistance by diastolic counter-pulsation with an intra-aortic balloon. This technique was used in 23 patients: 9 cases of cardiogenic shock due to acute myocardial infarction, 9 septal ruptures, 1 rupture of the papillary muscle of the mitral valve, 1 acute ventricular aneurysm, 2 high risk coronary arteriographies and 1 case of early post-infarction recurrent ischemia. It confirms the gravity of cardiogenic shock as, in spite of the frequent improvement in hemodynamic parameters under counter-pulsation, there was only one survivor. The efficacy is greater in cases of septal rupture, where the author obtained 3 survivors out of 6 operated cases. The security of the method and its innocuity permit one to carry out high risk coronary arteriography and extend the indications for circulatory assistance, to certain cases of unstable angina or early recurrent anginal following acute infarction.

Urgent heart transplantation in patients in irreversible cardiogenic shock or with low cardiac output unresponsive to sympathomimetic drugs has recently been shown to be possible [1]. This life-saving procedure may be performed either immediately, if a suitable donor is available, or later following a period of mechanical support [2, 3]. Various techniques have been evaluated during the past 2 years: prolonged extracorporeal circulation with membrane oxygenation [4, 5], paracorporeal or internal ventricular assist devices (VADs) [2, 6, 7], and the implantable total artificial heart (TAH) [3, 8–12].

It is correct to add hormone or chemotherapy in advanced metastatic disease of endometrial carcinoma and in recurrences. Large doses of hormone treatment have to be given. These are progestagens and the success rate with them, no matter which product is used, is approximately 30%. The use is limited by high blood pressure and the risks of vascular complications and metabolic upsets. Tamoxifen seems to the better tolerated and gives similar results. The response to hormone treatment depends on how sensitive the tumor is to the hormones. It is better when it has large numbers of progesterone receptors and it is of low grade. When the tumour is resistant to hormones, chemotherapy with cytotoxic drugs should be used. These drugs are adriamycine and mono or combined chemotherapy, but there is no protocol as yet that is better than any other. The debate about whether to use adjuvant treatment in stage I or II cases is open. It must be considered when the prognosis seems to be bad or there seem to be large risks of recurrences.

Transluminal coronary angioplasty (TCA) is an attractive means of suppressing ischaemia in patients (pts) with unstable angina. Sixty consecutive pts underwent TCA 6 +/- 2.5 days on average after their admission. Only the ischaemic vessel was dilated (mean stenosis 79 p. 100). Primary success was obtained in 53 pts (88 p. 100) with 31 p. 100 of residual stenosis after TCA. Two pts underwent emergency surgery for extensive dissection; failure of traversing the stenotic segment occurred in 2 pts; 3 pts had myocardial infarction (MI) less than 1 h after TCA, 2 arteries have been recanalized by intracoronary streptokinase with persistence of a satisfactory result of TCA, the 3rd patient had occlusion of a secondary side branch. During their stay in hospital, 2 pts had coronary bypass for recurrent angina. After a follow-up period of 6 to 16 months (mean 10 months) early recurrence of angina was observed in a number of cases (before the sixth month in 7 pts). One pt developed MI during the fourth month. At six month, 10 or the initial 60 pts had undergone coronary bypass, 1 undilated pt was asymptomatic; out of 49 dilated pts (47 with one single TCA), 39 were symptom-free but 6 had a positive exercise test, 7 pts were in class II and one in class IV. At control coronary arteriography (46 pts) restenosis was present in 39 p. 100: 5 new TCA and 2 aorto-coronary bypasses were performed. At one year 28 pts had been followed up: 1 was in class IV and 1 in class II, the others being asymptomatic.(ABSTRACT TRUNCATED AT 250 WORDS)

Nitro-compounds exert a preventive action on myocardial ischaemia through their peripheral effects (reduction of left ventricular preload) and their effects on the coronary system (increase of collateral flow and imprevement in the endocardium: epicardium perfusion ratio). The haemodynamic, coronary and metabolic effects of Risordan i.v. infusions (5 mg/h) in acute myocardial ischaemia induced by rapid atrial stimulation (RAS) were investigated in 15 male patients with angiographic or ECG signs of non-perfusion of the coronary network. Coronary sinus blood flow was measured by the thermodilution method. The values measured or calculated were: heart rate (HR), cardiac index (CI), aortic pressure (PAo), pulmonary capillary pressure (PCP), right atrial pressure (RAP), systemic arterial resistance (SAR), double product (DP), coronary blood flow (QCcor), total coronary resistance (TCR), O2 arterio venous difference (DAVO2), myocardial O2 consumption (MVO2) and myocardial lactate extraction (K %). RAS produced a significant increase of PAo, CI, DP, MVO2 and QCcor, with inversion of K % (-3.3%) indicatif anaerobic metabolism by myocardial ischaemia. Risordan produced significant diminution of PAo and CI with subsequent increase of HR; there was little increase of DP, MVO2 and QCcor and little change n myocardial metabolism (K % = 14 %). Risordan corrected the myocardial ischaemia induced by RAS, with decrease of PAo, PCP, RAP, CI, DP and QCcor, K % became positive (+ 11.5 % vs -3.3 % during RAS) suggesting a decrease in myocardial ischaemia.